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S M A R T
Smart Plan
PLAN
B
Your health
is everything
1
The Discovery Health Medical
Scheme is the best choice for you
CONSUMERS BUSINESS
In a global study by Deloitte, Discovery Health Medical Scheme has been ranked among
the top 3 health insurers in the world since 2008, based on financial security, contribution levels,
membership and innovation.
The benefits explained in this brochure are provided by Discovery Health Medical Scheme, registration number 1125, administered by Discovery Health (Pty) Ltd,
registration number 1997/013480/07, an authorised financial services provider. This brochure is only a summary of the key benefits and features of Discovery
Health Medical Scheme plans, awaiting formal approval from the Council for Medical Schemes. In all instances, Discovery Health Medical Scheme Rules prevail.
Please consult the Scheme Rules on www.discovery.co.za. When reference is made to “we” in the context of benefits, members, payments or cover, in this brochure
this is reference to Discovery Health Medical Scheme. Vitality is a separate wellness product sold and administered by Discovery Vitality (Pty) Ltd. Registration
number 1999/007736/07, an authorised financial services provider.
2
Comprehensive Better Better Lower
benefits healthcare health cost
The lower cost analysis is a comparison of our contributions with competitor contributions, based on internal analysis of publicly available marketing material.
Vitality is not part of the Discovery Health Medical Scheme. Vitality is a separate wellness product sold and administered by Discovery Vitality (Pty) Ltd.
Registration number 1999/007736/07, an authorised financial services provider.
3
Key features
Guaranteed full cover in hospital for Rich cover for a defined list of acute
specialists we have a payment arrangement medicine with a R10 co-payment per item
with, and up to 200% of the Discovery Health in our Smart Plan network
Rate for other healthcare professionals
Full cover for video call consultations
Full cover for chronic medicine for all with a GP in a Smart Plan network
Chronic Disease List conditions when
you use MedXpress, Clicks or Dis-Chem Cover for medical emergencies
when travelling
Vitality is not part of the Discovery Health Medical Scheme. Vitality is a separate wellness product sold and administered
by Discovery Vitality (Pty) Ltd. Registration number 1999/007736/07, an authorised financial services provider. 4
You get unlimited hospital cover
There is no overall limit to hospital cover on all Discovery Health Medical Scheme plans.
Your hospital cover is made up of the account from the hospital and the accounts
from your admitting doctor, anaesthetist and any other approved healthcare professional.
5
Prescribed Minimum Benefit (PMB) conditions
In terms of the Medical Schemes Act of 1998 If your treatment doesn’t meet the above criteria,
(Act number 131 of 1998) and its Regulations, we will pay up to 80% of the Discovery Health Rate.
all medical schemes have to cover the costs You will be responsible for the difference between
related to the diagnosis, treatment and care of: what we pay and the actual cost of your treatment.
A life-threatening emergency
medical condition; and What is the Discovery Health Rate (DHR)
A defined list of 270 diagnoses.
A defined list of 27 chronic conditions. This is a rate set by us at which healthcare services
from hospitals, pharmacies and healthcare
To access Prescribed Minimum Benefits,
professionals are paid.
there are rules that apply:
6
Hospital cover
There is no overall limit for your hospital cover. This is how we cover your hospital account
and accounts from your admitting doctor, anaesthetist or other approved
healthcare professionals (related accounts):
Hospital accounts
Hospital account Covered in full at the rate agreed with the hospital
Related accounts
MRI and CT scans If done as part of your admission, we cover your scan
up to 100% of the DHR from the Hospital Benefit.
If not related to your admission or if for conservative back
and neck treatment, you will have to pay the first R2 750
and the balance will be paid from the Hospital Benefit.
Scopes You must pay the first R3 550 of the hospital account.
(gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) The balance of the hospital account and related
accounts will be paid from the Hospital Benefit.
7
Hospital cover
8
Hospital cover
The Severe Dental and Oral Surgery Benefit covers There is no overall dental limit. However, you
a defined list of procedures, with no upfront must pay for the cost of all dental appliances,
payment and no overall limit. This benefit is subject their placements and orthodontic treatment
to authorisation and the Scheme’s clinical rules. (including the related accounts for orthognathic
surgery) yourself.
9
You get extensive cover for chronic
conditions and cancer
Members living with a chronic illness or cancer get the best care
and support at all times through our suite of programmes
The Chronic Illness Benefit You have access to a list You get full cover for approved
(CIB) covers you for a defined of medical conditions and chronic medicine on our
list of chronic conditions. treatments under Prescribed medicine list.
You need to apply to have Minimum Benefits (PMBs).
your medicine covered The PMBs cover the 27 chronic
for your chronic condition. conditions on the Chronic
How we pay
Disease List (CDL) conditions for medicine
(see page 6).
We pay for medicine up to
a maximum of the Discovery
Health Rate for medicines.
The Discovery Health Rate
for medicines is the price
of medicine as well as a fee
for dispensing it.
10
Chronic conditions we cover
Chronic Addison’s disease, Asthma, Bipolar mood disorder, Bronchiectasis, Cardiac failure, Cardiomyopathy, Chronic
Disease obstructive pulmonary disease (COPD), Chronic renal disease, Coronary artery disease, Crohn’s disease,
List (CDL) Diabetes insipidus, Diabetes type 1, Diabetes type 2, Dysrhythmia, Epilepsy, Glaucoma, Haemophilia, HIV,
conditions Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple sclerosis, Parkinson’s disease, Rheumatoid arthritis,
Schizophrenia, Systemic lupus erythematosus, Ulcerative colitis
To avoid a 20% co-payment, you have Get your monthly medicine by using MedXpress,
to use MedXpress, Clicks or Dis-Chem. an ordering service that delivers or allows
in-store collection (see page 19).
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Suite of patient management programmes
If you are registered on CIB for diabetes or a defined When you register for our HIVCare Programme you
list of heart-related conditions, you can access our are covered for the care that you need. You can
Personal Health Programmes to help better manage be assured of confidentiality at all times.
your condition (see page 20).
If you’re diagnosed with cancer and once we All cancer-related healthcare services are
have approved your cancer treatment, you covered up to 100% of the DHR. You might have
are covered by the DiscoveryCare Oncology a co-payment if your healthcare professional
Programme. We do not limit your cancer charges above this rate.
treatment costs. We cover the first R200 000
Advanced Illness Benefit
of your approved cancer treatment over a
12-month cycle in full. If your treatment costs Members with cancer have access to a
more than the cover amount, you will need comprehensive palliative care programme.
to pay 20% of the additional costs. Cancer This programme offers unlimited cover for
treatment that is a Prescribed Minimum approved care at home for members
Benefit is always covered in full. with cancer.
Compassionate care
The Compassionate Care Benefit gives you access to holistic home-based end-of-life care up to R48 000
for each person in their lifetime.
12
You get screening and
prevention benefits
As a Discovery Health Medical Scheme member, you have access to screening and prevention
benefits that cover the following at any one of our wellness providers:
How we pay
Having these healthcare services (up to a specified number) does not affect your day-to-day benefits as
we pay these costs from the Hospital Benefit. Visit www.discovery.co.za for more information.
13
You get cover for day-to-day
medical expenses
14
You also get additional benefits
that enhance your cover
15
Contributions
Main
member Adult Child*
* We count a maximum of three children when we work out the monthly contributions.
16
Smart Hospital Network
Gauteng KwaZulu-Natal
Free State
Mediclinic Bloemfontein
Visit www.discovery.co.za for the latest list of hospitals and casualty units. Please note that this list is subject to change.
17
Tools and
services
to improve
your health
18
MedXpress
Discovery MedXpress is a convenient medicine ordering service, particularly for monthly chronic
medicine. Using Discovery MedXpress or a pharmacy that is in the designated service provider
network will ensure you get favourable rates for your approved chronic medicine.
Y
ou have full cover It is quick and convenient Y
ou can reorder your
with no co-payments Delivery is free anywhere chronic medicine when
for medicine on our it’s convenient for you
You receive advice
medicine list
and updates
MedXpress is brought to you by Discovery Health (Pty) Ltd. Registration number 1997/013480/07, an authorised financial services provider. *Selected stores
19
Personal Health Programmes
Our Personal Health Programmes are unique lifestyle programmes to assist you –
with the help of your Premier Practice GP – to actively manage your chronic condition
to make you healthier.
Personal Health Programmes are brought to you by Discovery Vitality (Pty) Ltd, registration number 1999/007736/07 and Discovery Health (Pty) Ltd,
registration number 1997/013480/07. Authorised financial services providers. 20
Discovery HomeCare
Discovery HomeCare is a unique home-based service that offers you quality care in the comfort
of your own home, with minimum disruption to your normal routine and family life.
Wound care for venous ulcers, diabetic foot ulcers, pressure sores and
Wound care
other moderate to severe wounds for patients whose condition is stable
and hospital admission is not required.
These services are paid from the Hospital Benefit, subject to approval.
Discovery HomeCare is brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider.
21
Claiming made
easier and faster
Email
Post your claims to:
Discovery Claims
Scan and email your claims to:
PO Box 784262, Sandton 2146
claims@discovery.co.za
22
HealthID
HealthID is the first electronic health record application of its kind in South Africa. It puts
all your health records in your doctor’s hands so you won’t have to try and remember everything.
It also assists your doctor in interacting with us.
To benefit from HealthID, you will need to No unauthorised person will have access
give consent to each doctor you visit before to your personal medical information.
that doctor can access your health records.
1 2 3
4 5 6
HealthID is brought to you by Discovery Health (Pty) Ltd. Registration number 1997/013480/07, an authorised financial services provider.
23
Tools to help better
manage your health plan
The Discovery app and website have both
been purpose-built to help you get the most
out of your health plan
24
Access to value-added
healthcare offers
You have exclusive access to value-added offers outside of the Discovery Health Medical Scheme
benefits and rules that are not available to members of other open medical schemes.
Vitality is not part of the Discovery Health Medical Scheme. Vitality is a separate wellness product sold and administered by Discovery
Vitality (Pty) Ltd. Registration number 1999/007736/07, an authorised financial services provider. HealthyCare is brought to you
by Discovery Vitality (Pty) Ltd. Registration number 1997/007736/07, an authorised financial services provider. Netcells® Biosciences
is brought to you by Discovery Health (Pty) Ltd. Registration number 1997/013480/07, an authorised financial services provider.
25
General exclusions
We do not pay for healthcare services related to the following, except where stipulated as part
of a defined benefit or under the Prescribed Minimum Benefits
Waiting periods:
If we apply waiting periods because you have never belonged to a medical scheme or have had a break in
membership of more than 90 days before joining the Discovery Health Medical Scheme, you will not have access
to the Prescribed Minimum Benefits during your waiting periods. This includes cover for emergency admissions.
If you had a break in cover of less than 90 days before joining the Discovery Health Medical Scheme, you may
have access to Prescribed Minimum Benefits during waiting periods.
26
Complaints
Discovery Health Medical Scheme is committed to providing you with the highest standard
of service and your feedback is important to us. The following channels are available
for your complaints and we encourage you to follow the process.
If you have already contacted us and feel that your query has still not been resolved, please complete
our online complaints form on the website. We would also love to hear from you if we have exceeded
your expectations.
If you are still not satisfied with the resolution of your complaint after following the process in step 1
you are able to escalate your complaint to the Principal Officer of the Discovery Health Medical Scheme
by completing the online form on the website.
If you have received a final decision from Discovery Health Medical Scheme and want to challenge it, you may
lodge a formal dispute. You can find more information on the Scheme’s disputes process on the website.
Discovery Health Medical Scheme is regulated by the Council for Medical Schemes (CMS). You may contact
the CMS at any stage of the complaints process but are encouraged to follow the steps above to resolve your
complaint before contacting the CMS directly. Members who wish to approach the Council for Medical Schemes
for assistance, may do so in writing to: Council for Medical Schemes Complaints Unit, Block A, Eco Glades 2 Office
Park, 420 Witch - Hazel Avenue, Eco Park, Centurion, 0157 or email complaints@medicalschemes.com.
Customer care centre: 0861 123 267 / website www.medicalschemes.com
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Discovery Health Medical Scheme
Discovery Health Medical Scheme is regulated by the Council for Medical Schemes.
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